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Alcohol Septal Ablation in Hypertrophic Obstructive Cardiomyopathy

Alcohol Septal Ablation in Hypertrophic Obstructive Cardiomyopathy. John F. Robb, MD Associate Professor of Medicine Director, Cardiac Catheterization Laboratories. December 6, 2004. Alcohol Septal Ablation. Case Presentation The patient is a 61 year old female History of lifelong murmur

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Alcohol Septal Ablation in Hypertrophic Obstructive Cardiomyopathy

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  1. Alcohol Septal AblationinHypertrophic Obstructive Cardiomyopathy John F. Robb, MD Associate Professor of Medicine Director, Cardiac Catheterization Laboratories December 6, 2004

  2. Alcohol Septal Ablation Case Presentation • The patient is a 61 year old female • History of lifelong murmur • Followed for about 10 years with echocardiography for hypertrophic obstructive cardiomyopathy • 9 months of increasing dyspnea on exertion: • NYHA Class III, < 1 flight, <1 block • No orthopnea, PND, or edema • CCS class III exertional angina • Humid weather = “big elephant” • Dry weather = “small elephant” • Frequent lightheadedness, one episode of syncope 30 years ago

  3. Alcohol Septal Ablation Case Presentation • Treated with calcium blockers for 8 years, but never tried on beta blockers or disopyramide. • Trial of beta blockers resulted in worsened dyspnea on exertion and dizziness, with episodes of pre-syncope

  4. Alcohol Septal Ablation Case Presentation • Past Medical History: • Asthma • Hypothyroidism • Hepatic angioma • Elevated cholesterol • s/p strabismus surgery yrs ago • Social History: • Tax preparer, married mother of 4 children • Non-smoker

  5. Alcohol Septal Ablation Case Presentation • Work up at another institution included • Echocardiography showing diffuse LV hypertrophy with asymmetric septal thickening and a resting ~ 64 mmHg gradient across the LVOT which increased to > 100 mmHg with Valsalva maneuver • Cardiac catheterization LVEF 84% 50 mmHg resting LVOT gradient, LV Systolic pressure increased from 140 mmHg to 260 mmHg with Valsalva and post PVC. Coronary arteries were normal. There was + 2-3 mitral regurgitation.

  6. Alcohol Septal Ablation Case Presentation • Surgical mitral valve replacement and septal myomectomy was recommended with a quoted 3-5% operative mortality. • Patient and her husband sought a second opinion.

  7. Alcohol Septal Ablation Case Presentation • Physical Exam: • BP-140/70, P-80, R-12 • Chest clear • Cor- 2/6 systolic ejection murmur left sternal border which increases in intensity and duration with Valsalva, +S4 • Abdomen obese without organomegaly • Trace edema

  8. Alcohol Septal Ablation Case Presentation • EKG:

  9. Alcohol Septal Ablation Case Presentation • Echocardiogram • Moderate concentric LVH • Asymmetric septal hypertrophy, 2 cm • Systolic anterior motion of the mitral valve • Dynamic LVOT gradient ~ 100 mmHg at rest • +2/+4 mitral regurgitation • LVEF 75% without regional wall motion abnormalities • Estimated RV systolic pressure 41 mmHg

  10. Alcohol Septal AblationPre Echo

  11. Alcohol Septal AblationPre Echo

  12. Alcohol Septal AblationPre Echo

  13. Alcohol Septal AblationPre Echo

  14. Alcohol Septal AblationHemodynamics Pre

  15. Alcohol Septal AblationHemodynamics Pre RV Pacing

  16. Alcohol Septal AblationCath angio

  17. Alcohol Septal Ablation Cath angio

  18. Alcohol Septal Ablation Cath angio

  19. Alcohol Septal AblationEcho Procedure

  20. Alcohol Septal AblationHemodynamics post

  21. Alcohol Septal AblationEcho Procedure Post Pre

  22. Alcohol Septal Ablation Case Presentation • Temporary pacer • 2 cc absolute ETOH administered • Mild chest pain • Occlusion of the 1st septal on follow-up angiography • Transient complete heart block, resolved in 10 minute • Procedural Echo: • LVOT gradient was reduced from 84 to 14 mmHg • SAM resolved, LVEF 75%, 1-2+ MR • CK rose to 1339, Troponin T to 3.86 • No arrhythmias noted on telemetry • Discharged to home at post procedure day 3

  23. Alcohol Septal Ablation Case Presentation • Post EKG

  24. Alcohol Septal Ablation Case Presentation Follow-up 30 days: • Dyspnea and angina resolved, Class 0 • No dizziness or syncope • Calcium blocker continued for hypertension • Echo 30 days: • No resting LVOT gradient • 95 mmHg LVOT gradient with Valsalva • 1-2+ MR • LVEF 75%

  25. Alcohol Septal AblationEcho 180 days post

  26. Alcohol Septal AblationEcho 30 days post Rest Valsalva

  27. Alcohol Septal Ablation Case Presentation • 30 day EKG:

  28. Alcohol Septal Ablation Case Presentation Follow-up 180 days: No angina, dyspnea, dizziness or syncope Fully active without symptoms “Feels great!” Calcium Channel blocker weaned

  29. Alcohol Septal AblationEcho 180 days post • Echo 180 days • Moderate LVH • No LVOT gradient at rest or with Valsalva • 1-2+ MR • LVEF 75% • RV systolic pressure 30 mmHg

  30. Alcohol Septal AblationEcho 30 days post

  31. Alcohol Septal AblationEcho 180 days post Rest Valsalva

  32. Alcohol Septal AblationOutcomes • 213 consecutive symptomatic patients • Followed for 4 years • 97% procedures successful • 1% repeat procedures • 15% permanent pacers • Mortality • Overall 4% • Procedural 1% • Sudden death 1% • Non-cardiac 2% • Better outcome if: • LVOT gradient < 25 mmHg at time of procedure • CK ≥ 1300 Spencer, JACC 2002 Spencer, Circulation 2004 109:824

  33. Alcohol Septal AblationOutcomes Spencer, JACC 2002

  34. Alcohol Septal Ablation Surgical Myomectomy • 1-5% mortality • Morbidity of median sternotomy, cardiopulmonary bypass • Few expert centers • 10-20% mortality in elderly A-V Pacing • Blinded crossover studies: no significant long term symptom relief

  35. Alcohol Septal Ablation

  36. Alcohol Septal AblationTherapy Holmes, NEJM 2004 350:1320

  37. Alcohol Septal Ablation Interventricular septal reduction with alcohol ablation is a useful non- surgical approach to patients with hypertrophic obstructive cardiomyopathy who remain symptomatic despite medical therapy.

  38. Alcohol Septal AblationHemodynamics Pre Hemodynamics of HOCM • Brisk Ao upstroke, late systolic gradient • Brockenbrough Braunwald Morrow sign • Increased LVOT gradient following PVC • Decreased Ao pulse pressure following PVC • Increased LVOT gradient with: • Decreased LV end diastolic volume • Shortened diastole • Decreased LA pressure • Increased contractility • Decreased aortic impedence • Valsalva • Nitroglycerin • PVC’s • Dobutamine or isoproterenol • Exercise

  39. Alcohol Septal AblationHemodynamics post

  40. Alcohol Septal AblationHemodynamics post

  41. Alcohol Septal AblationHemodynamics post

  42. Alcohol Septal AblationHemodynamics post

  43. Alcohol Septal AblationHemodynamics Pre Valsalva

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